<!--
  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
  along with this program.  If not, see <http://www.gnu.org/licenses/>.
  =========================LICENSE_END==================================
  -->
<wicket:extend xmlns:wicket="http://www.w3.org/1999/xhtml">
    <div class="row-fluid">
        <div class="span12">
            <h1 class="pageTitle" wicket:id="label">Organisatiegegevens</h1>
        </div>
    </div>
    <div class="row-fluid form-horizontal">
        <div wicket:id="dialog"></div>
        <fieldset>
            <wicket:container wicket:id="paspoort"/>

            <form wicket:id="organisatieForm">
                <fieldset>
                    <div class="row-fluid">
                        <div class="span6">
                            <div class="control-group">
                                <label class="control-label">Naam organisatie </label>
                                <div class="controls">
                                    <input class="input-large" type="text" value="Organisatie 1"
                                           wicket:id="naam">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Straatnaam</label>
                                <div class="controls">
                                    <input class="input-large" type="text" value="Straatnaam"
                                           wicket:id="adressen[0].straat">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Huisnummer + toevoeging</label>
                                <div class="controls">
                                    <input class="input-small" type="text" value="123"
                                           wicket:id="adressen[0].huisnummer"> <input
                                        class="input-mini" type="text" value="A"
                                        wicket:id="adressen[0].huisnummerToevoeging">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Postcode</label>
                                <div class="controls">
                                    <input class="input-mini" type="text" value="1234 AB"
                                           wicket:id="adressen[0].postcode">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Plaats</label>
                                <div class="controls">
                                    <input class="input-large" type="text" vaule="Plaatsnaam"
                                           wicket:id="adressen[0].plaats">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Postbusnummer</label>
                                <div class="controls">
                                    <input class="input-small" type="text" value="1233"
                                           wicket:id="adressen[1].huisnummer">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Postbusnummer postcode</label>
                                <div class="controls">
                                    <input class="input-mini" type="text" value="4321 ZY"
                                           wicket:id="adressen[1].postcode">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Postbusnummer plaats</label>
                                <div class="controls">
                                    <input class="input-large" type="text" value="Plaatsnaam"
                                           wicket:id="adressen[1].plaats">
                                </div>
                            </div>
                            <wicket:enclosure child="adressen[2].huisnummer">
                                <div class="control-group">
                                    <label class="control-label">Antwoordnummer</label>
                                    <div class="controls">
                                        <input class="input-small" type="text" value="1233"
                                               wicket:id="adressen[2].huisnummer">
                                    </div>
                                </div>
                            </wicket:enclosure>
                            <wicket:enclosure child="adressen[2].postcode">
                                <div class="control-group">
                                    <label class="control-label">Antwoordnummer postcode</label>
                                    <div class="controls">
                                        <input class="input-mini" type="text" value="4321 ZY"
                                               wicket:id="adressen[2].postcode">
                                    </div>
                                </div>
                            </wicket:enclosure>
                            <wicket:enclosure child="adressen[2].plaats">
                                <div class="control-group">
                                    <label class="control-label">Antwoordnummer plaats</label>
                                    <div class="controls">
                                        <input class="input-large" type="text" value="Plaatsnaam"
                                               wicket:id="adressen[2].plaats">
                                    </div>
                                </div>
                            </wicket:enclosure>
                        </div>
                        <div class="span6">
                            <div class="control-group">
                                <label class="control-label">Telefoonnummer 1</label>
                                <div class="controls">
                                    <input class="input-medium" type="text" wicket:id="telefoon">
                                    <span style="font-style: italic; color: grey;" wicket:id="telNum1Label">t.b.v. Informatielijn nummer</span>
                                </div>
                            </div>

                            <div class="control-group">
                                <label class="control-label">Telefoonnummer 2</label>
                                <div class="controls">
                                    <input class="input-medium" type="text" wicket:id="telefoon2">
                                    <span style="font-style: italic; color: grey;" wicket:id="telNum2LabelSo">Algemeen nummer</span>
                                    <span style="font-style: italic; color: grey;" wicket:id="telNum2LabelCe">planning</span>
                                </div>
                            </div>

                            <wicket:enclosure child="telefoon3">
                            <div class="control-group">
                                <label class="control-label">Telefoonnummer 3</label>
                                <div class="controls">
                                    <input class="input-medium" type="text" wicket:id="telefoon3">
                                    <span style="font-style: italic; color: grey;">voor professionals</span>
                                </div>
                            </div>
                            </wicket:enclosure>

                            <wicket:enclosure child="telefoon4">
                            <div class="control-group">
                                <label class="control-label">Telefoonnummer 4</label>
                                <div class="controls">
                                    <input class="input-medium" type="text" wicket:id="telefoon4">
                                    <span style="font-style: italic; color: grey;">mindervalide (rolstoelafspraken)</span>
                                </div>
                            </div>
                            </wicket:enclosure>

                            <div class="control-group">
                                <label class="control-label">Faxnummer</label>
                                <div class="controls">
                                    <input class="input-medium" type="text" wicket:id="fax">
                                </div>
                            </div>

                            <div class="control-group">
                                <label class="control-label">E-mail</label>
                                <div class="controls">
                                    <input class="input-large" type="text" wicket:id="email">
                                    <span style="font-style: italic; color: grey;" wicket:id="emailLabel">t.b.v. Informatielijn nummer</span>
                                </div>
                            </div>

                            <wicket:enclosure child="email2">
                            <div class="control-group">
                                <label class="control-label">E-mail 2</label>
                                <div class="controls">
                                    <input class="input-large" type="text" wicket:id="email2">
                                    <span style="font-style: italic; color: grey;">planning</span>
                                </div>
                            </div>
                            </wicket:enclosure>

                            <wicket:enclosure child="email3">
                            <div class="control-group">
                                <label class="control-label">E-mail 3</label>
                                <div class="controls">
                                    <input class="input-large" type="text" wicket:id="email3">
                                    <span style="font-style: italic; color: grey;">voor professionals</span>
                                </div>
                            </div>
                            </wicket:enclosure>

                            <wicket:enclosure child="email4">
                            <div class="control-group">
                                <label class="control-label">E-mail 4</label>
                                <div class="controls">
                                    <input class="input-large" type="text" wicket:id="email4">
                                    <span style="font-style: italic; color: grey;">mindervalide (rolstoelafspraken)</span>
                                </div>
                            </div>
                            </wicket:enclosure>

                            <wicket:enclosure child="website">
                            <div class="control-group">
                                <label class="control-label">Website</label>
                                <div class="controls">
                                    <input class="input-large" type="text" wicket:id="website">
                                </div>
                            </div>
                            </wicket:enclosure>

                            <wicket:enclosure child="gemachtigde">
                            <div class="control-group">
                                <label class="control-label">Gemachtigde</label>
                                <div class="controls">
                                    <select wicket:id="gemachtigde"></select>
                                </div>
                            </div>
                            </wicket:enclosure>

                            <wicket:enclosure child="clientPortaalVrijeTekstContainer">
                                <div class="control-group">
                                    <label class="control-label">Informatie openingstijden</label>
                                    <div class="controls" wicket:id="clientPortaalVrijeTekstContainer">
                                        <textarea wicket:id="clientPortaalVrijeTekst"></textarea>
                                    </div>
                                </div>
                            </wicket:enclosure>
                        </div>
                    </div>
                </fieldset>
                <wicket:enclosure child="uziAbonneenummer">
                    <fieldset>
                        <div class="row-fluid">
                            <div class="span12">
                                <legend>Uziabonneenummer</legend>
                            </div>
                        </div>
                        <div class="row-fluid">
                            <div class="span6">
                                <div class="control-group">
                                    <label class="control-label">URA-nummer</label>
                                    <div class="controls">
                                        <input class="input-small" type="text"
                                               wicket:id="uziAbonneenummer">
                                    </div>
                                </div>
                            </div>
                        </div>
                    </fieldset>
                </wicket:enclosure>

                <wicket:enclosure child="rootOid">
                    <fieldset>
                        <div class="row-fluid">
                            <div class="span12">
                                <legend>Identificatie voor HL7v3 communicatie</legend>
                            </div>
                        </div>
                        <div class="row-fluid">
                            <div class="span6">
                                <div class="control-group">
                                    <label class="control-label">HL7 OID van insturend systeem (incl. extension,
                                        gescheiden door een '.')</label>
                                    <div class="controls">
                                        <input wicket:id="rootOid" class="input-large" type="text" value="">
                                    </div>
                                </div>
                            </div>
                        </div>
                    </fieldset>
                </wicket:enclosure>

                <div class="row-fluid">
                    <div class="span12">
                        <div class="form-actions btn-bottom">
                            <button wicket:id="inActiveren" class="btn">
                                <i class="icon-minus-sign"></i> <span
                                    wicket:id="inActiverenTitle">Verwijderen</span>
                            </button>
                            <button wicket:id="annuleren" class="btn">Annuleren</button>
                            <button wicket:id="opslaan" class="btn btn-primary">Opslaan</button>
                        </div>
                    </div>
                </div>
            </form>
        </fieldset>
    </div>
</wicket:extend>
